P - 78645� _
80�.-385 -ti
Home Duplex
Commercial Industria l
Air Cond. Htg. Equi
Dryer Range
"X" above the work covered 6
REQUEST FOR ELECTRICAL INSPECTION
Minnesota State Board of Electricity
1821 University Ave., Rm. S-128, St. Paul, MN 55104
Phone(612)642-0800
Apt. Bldg. Other: �// ,. New Addn
farm � j�e �.(' �G..- �`r= �'S Remod Re air
Water Htr. Load Mgmt. Other:
Elec. Heat Temp. Service
request. Enter remarks in this space and on the back of ihe whiie copy only.
Calculate Inspection Fee - This Inspection Request will not be accepted without ihe correct fee:
Other Fee # Service Entrance ' e Fee # Circuits/Feed�
Mobile Home Park Stal) 0 to 00 Amps �, 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 ' Ajnn Above 100
f
Fee
Trans ormer/Generator INSPECTOR S USE ONLY , TG � HL /�
Sign/Outline Ltg. Xfmr. ^1 ,,�A 7�isv
a� v�i � I� —
Alarm/Remote Conhol �/
Swimming Pool I'�/� -/�' 3� d�
I hereb certi that I ins ed ihe elechi I installation described he a s
Irrigation Boom RougMn ��� � ��3
Special Inspection
Final
Investigative Fee d�
THIS INSTALLATION MAY BE ORDERED ONNECTED IF NOT COMPLETED WITHIN 18 MONTHS.
OFFiCE USE ONLY This requast void�,D'inonths from validafion date printed in ihis box.
IIIIIIIIIIiillliliiilllllililllllll�IIIH�IIIIII � �- `�
* 0 8 0 2 3 8 5 5* � �� c3 ��, �/�,
� PLEASE PRINT OR TYPE
Request Dute Rou h-in ins ion r uired6 Yes
g pecF' eq ❑No Inspection Other Than Rough-In: ❑ Ready Now ill Call
� Z� O� �� �You musf call the inspector when ready) Dafe Ready:
I, ❑ licensed contractor owner hereby request inspection of ihe above electrical work at:
Job Address �Sheef, Box, or Roufe N.) Ciy Zip Code
�� �3'�� ,�r7t.e 55��3L
Secfion No. Township Name or No. Range No. Fire No. Co ly ,
� � �j O Z� ,�vZlOK�4-
Occupanf � Plwne No.
Cw iZ�e� �e✓-�.�t c�� 7(�3-5'1 J— 8�sCo
Power Supplier p�m.�
Contractor(Company
Mailing Address (Conkaclor w Own�r Performing Insfallalion�
Contractor License No.
�3' `' ,� N � �e. `' .�5� Z
`actor or Owner Performing Insfallation) Phone No.
� ? �� / `I
STATE BOARD COPY - EE INSTRUCiIONS ON BACK OF YELLOW COPY